Provider Demographics
NPI:1982105037
Name:NIEMIEC, MICHELLE (OPTICIAN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:NIEMIEC
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1097 ROUTE 55 STE 4
Mailing Address - Street 2:
Mailing Address - City:LAGRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540-5027
Mailing Address - Country:US
Mailing Address - Phone:845-471-7710
Mailing Address - Fax:845-471-7746
Practice Address - Street 1:1097 ROUTE 55 STE 4
Practice Address - Street 2:
Practice Address - City:LAGRANGEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12540-5027
Practice Address - Country:US
Practice Address - Phone:845-471-7710
Practice Address - Fax:845-471-7746
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010085156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05180227Medicaid